Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. (NLRS / NPSA 2013). The list of Never Events that can be linked to Perioperative setting are Wrong Site Surgery, wrong implant / prosthesis, retained foreign objects post operation, misidentification of patients, to name a few (DOH 2013). Patient safety within the perioperative environment is paramount since this field is a critical area. Even with the implementation of preventative measures, avoidable harm still occurs. We are continuing to develop safety nets based on lessons learned from serious adverse incidents.
• Know how a “never event” is defined and investigated • Understand the Policy Framework of Never Events for use in the NHS. • Identify current list of Never Events 2012/2013 DoH • Be aware of Never Events that could occur in your area of clinical practice, • Awareness of the causes of perioperative “Never Events” • Identify possible preventative actions after a Never Events.
This workshop will enable participants to discuss issues identified surrounding avoidable harm and share lessons learned from a Never Events within the perioperative environment.